family-based treatment models targeting substance use and ...2005... · relationships persist...

Family-Based Treatment Models TargetingSubstance Use and High-Risk Behaviors

Among Adolescents:A Review

Sanna J. Thompson, PhDElizabeth C. Pomeroy, PhD

Kelly Gober, MSSW

SUMMARY. Recent reviews of services for families with youths copingwith a wide variety of problems have strongly urged inclusion of familiesin all services. This manuscript will review family-based interventionmodels that have considerable empirical support for treating adolescentsubstance abuse and have demonstrated success in preventing substanceuse. Major interventions reviewed include: Multisystemic Family Ther-apy, Strengthening Families Program, Brief Strategic Family Therapy,

Sanna J. Thompson, Elizabeth C. Pomeroy, and Kelly Gober are affiliated with the Uni-versity of Texas at Austin School of Social Work.

Address correspondence to: Sanna Thompson, PhD, University of Texas at AustinSchool of Social Work, Substance Abuse Research Development Program, 1717 West6th Street, Suite 335, Campus Box R5000 Austin, TX 78703 (E-mail: [email protected]).

[Haworth co-indexing entry note]: “Family-Based Treatment Models Targeting Substance Use andHigh-Risk Behaviors Among Adolescents: A Review.” Thompson, Sanna J., Elizabeth C. Pomeroy, andKelly Gober. Co-published simultaneously in Journal of Evidence-Based Social Work (The Haworth SocialWork Practice Press, an imprint of The Haworth Press, Inc.) Vol. 2, No. 1/2, 2005, pp. 207-233; and: Addic-tion, Assessment, and Treatment with Adolescents, Adults, and Families (ed: Carolyn Hilarski) The HaworthSocial Work Practice Press, an imprint of The Haworth Press, Inc., 2005, pp. 207-233. Single or multiple cop-ies of this article are available for a fee from The Haworth Document Delivery Service [1-800-HAWORTH,9:00 a.m. - 5:00 p.m. (EST). E-mail address: [email protected]].

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Digital Object Identifier: 10.1300/J394v02n01_12 207

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Multidimensional Family Therapy, and Integrated Behavioral FamilyTherapy. [Article copies available for a fee from The Haworth Document DeliveryService: 1-800-HAWORTH. E-mail address: <[email protected]>Website: <http://www.HaworthPress.com> © 2005 by The Haworth Press, Inc.All rights reserved.]

KEYWORDS. Family, treatment, adolescents, substance use, risky be-haviors

FAMILIES AND HIGH-RISK YOUTH

Some have argued that families are central to the process of youth de-veloping emotional and behavioral problems (Paradise, Cauce, Ginzler etal., 2001). Researchers contend that the relationship between vulnerabil-ity and risk becomes cemented early in life through a series of negativeinteractions between parent and child. The resulting difficulties in familyrelationships persist throughout childhood and adolescence. Poor familymanagement, lack of positive parenting skills, and dysfunctional care-giving have been strongly related to substance use and delinquency ofyouth (Formoso, Gonzales, & Aiken, 2000). Conversely, family supporthas been shown to predict positive adjustment in childhood and adoles-cence; indirect evidence suggests that family support is a protective factorfor adolescent substance use and conduct problems (Cauce, Reid, Land-esman, & Gonzales, 1990; Wills & McNamara, 1992).

Given the family’s fundamental influence on a child’s life, researchhas consistently suggested potential benefits for including families intreatment of high-risk youth. Prevention efforts with delinquent anddrug-abusing youth suggest that the single most effective form of pre-vention involves working with the total family system (Kumpfer, Alex-ander, McDonald, & Olds, 1998). Identification of situations wherefamilies may be engaged in services is a potentially beneficial methodfor addressing problems experienced by youth.

SUBSTANCE USE AND ADOLESCENTS

Rates of substance use among adolescent populations have becomean increasing problem as the rates of substance use and abuse amongAmerican high school and college students is the highest in the industri-

208 Addiction, Assessment, and Treatment with Adolescents, Adults, and Families

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alized world (Johnston, O’Malley, & Bachman, 2002). In 1997, rates ofsubstance use among youth 12 to 17-years of age rose to 11.7% and il-licit drug use among 12-13 year-olds increased from 2.2% to 3.8% dur-ing this time period (Winters, 1999). It appears that substance use isoccurring at earlier ages; some report that by age 16, half of male and fe-male adolescents use alcohol regularly and one-quarter use marijuana(Huizinga, Loeber, & Thornberry, 1994).

Data from Monitoring the Future study (Johnston et al., 2002) sug-gest that adolescent drug users are often found in the juvenile justice andeducational systems. Adolescents with alcohol/drug problems are oftenidentified as delinquent, having histories of child abuse and neglect, andsuffering from comorbid psychiatric conditions, especially depressionand suicidality (Hawkins, Catalano, & Miller, 1992; Rahdert, & Czech-owicz, 1995). Adolescents with family histories of alcoholism also re-port greater positive expectancies related to using substances, such assexual enhancement and feelings of power/aggression, than do youthwithout family histories of alcohol abuse (Lundahl, Davis, Adesso, &Lukas, 1997).

FAMILY-BASED INTERVENTIONS

Recent reviews of services for families with youths coping with awide variety of problems have strongly urged inclusion of families in allservices (Burns, & Weisz, 2000). Many studies (e.g., Liddle, Dakof,Parker et al., 2001; Kumpfer, 1998; Henggeler, Borduim, Melton et al.,1991; Szapocznik & Williams, 2000) have demonstrated that fam-ily-oriented interventions are critical in reducing risk factors associatedwith substance use and these intervention models have considerableempirical support for demonstrated success in preventing adolescentsubstance use. Family therapies have developed from two foundationaltherapies that originated in the early 1970s. Structural Family Therapy,developed by Salvador Minuchin, and Strategic Family Therapy, devel-oped by Jay Haley, are built on the assumptions that (1) families arerule-governed systems that can best be understood in context, (2) thepresenting problem serves a function within the family, and (3) the con-cepts of boundaries, coalitions, hierarchy, power, metaphor, family lifecycle development and triangles are basic to the development of a“stuck” family (Minuchin, 1974; Haley, 1973; Nichols & Schwartz,1995). These therapeutic models are the core theories from which latermodels developed.

Thompson, Pomeroy, and Gober 209

Currently, research studies have been initiated that evaluate varioustreatment modalities targeting adolescent substance use. Many of thesestudies include testing structured and manualized family interventionsdeveloped during the past two decades. For example, multi-systemictherapy (MST), strengthening family program (SFP), brief strategicfamily therapy (BSFT), multidimensional family therapy (MDFT), andintegrated behavioral family therapy (IBFT). This manuscript reviewsthe empirical studies of these family-based interventions that have anemphasis on adolescent substance use. See Table 1 for a brief descrip-tion of these studies.

MULTISYSTEMIC THERAPY

Multisystemic therapy (MST) treatment views individuals in terms ofthe complex systems in which they are embedded (Letourneau,Cunningham, & Henggeler, 2002). Individuals restructure their environ-ments while simultaneously being influenced by them. Behavior is bestunderstood when viewed within broader contexts, such as school, family,peers, neighborhood, services, and community institutions (Henggeler,Schoenwald, Borduin et al., 1998).

MST has been extensively evaluated, and suggests that antisocial be-havior in youth is determined by a variety of correlates (Henggeler et al.,1998). These factors, along with other antisocial behaviors, such as con-duct disorder and delinquency, are relevant for substance abuse (Hawkinset al., 1992; Kumpfer, DeMarsh, & Child, 1989); MST lends itself tothese complex issues. The number of individual therapy sessions variesdepending on the problems within the system; however, parent trainingtypically occurs in 10 sessions (Henggeler et al., 1998).

Growing evidence supports the effectiveness of MST for substance-using adolescents. Stanton and Shadish (1997) conducted a meta-analysisof family-based treatments for drug use and found that MST effect sizeswere among the highest of those reviewed. An early MST outcome study(Henggeler, 1986) used a quasi-experimental design to study youth andtheir families in a delinquency diversion program. Findings showed theMST was more effective than usual community services in terms of clientbehaviors and family relationships. Subsequently, MST has been sub-stantiated as an evidenced- based treatment for adolescents and their fam-ilies in randomized clinical trials. It has been effective in reducingout-of-home placements, delinquent behavior, substance use, and psychi-atric disorders (Sheidow & Woodford, 2003).



TABLE 1. Studies of family-based treatment with focus on adolescent sub-stance use.

Reference Design Sample Outcome Variables

Multi-Systemic Therapy

Henggeler, 1986 Quasi-Experimental;pre- and post-treat-ment assessments

n = 57–familyecologicaln = 23–alternativen = 44–controlYouth and familiesin a delinquencydiversion program

Personality InventoryFamily relationsBehavior Problems:conduct problems,anxious–withdrawnbehaviors, immaturity,and association withdelinquent peers

Henggeler, Melton,& Smith, 1992;Henggeler et al.,1991

MSFT vs. standardjuvenile justice

services

n = 84 juvenileoffendersRandom assignment

Alcohol and marijuanauseIncarceration/recidivismViolenceCriminal Activity

Henggeler et al.,1993

MST vs. standardjuvenile justiceservices follow-up

n = 84 juvenileoffendersRandom assignment

Alcohol and marijuanauseIncarceration/recidivismAggression with peersCriminal activityFamily cohesion

Borduin et al.,1995; Henggeleret al., 1991

MST vs. individualtherapy

n = 200 violentjuvenile offendersand familiesRandom assignment

Arrest types:Substance use/violentcrimesArrest recidivism

Henggeler, Pickrel,& Brondino, 1996

Home-based MSTvs. usual communityservices

n = 118 substanceabusing or dependentjuvenile delinquentsand familiesRandom assignment

Retention rates

Schoenwald,Ward, &Henggeler, 1996

Home-based MSTvs. usual communityservices

n = 118 substanceabusing or dependentjuvenile delinquentsand familiesRandom assignment

Costs of treatment

Henggeler, Melton,Brondino, Scherer,& Hanley, 1997


n = 155 adolescentsRandom assignment

Adherence to MSTArrests/recidivismIncarceration/recidivism

Brown, Henggeler,& Schoenwald,1999

MST vs. standardcommunity-basedservice

n = 118 substanceabusing or dependentjuvenile delinquentswith co-morbidpsychiatric disordersand familiesRandom assignment

School attendanceMental healthAdherence to MSTArrests/recidivismIncarceration/recidivism


TABLE 1 (continued)



Henggeler,Pickrel,& Brondino,1999


n = 118 substanceabusing or dependentjuvenile delinquentsand their families

Alcohol and marijuanausePsychiatric SymptomsArrest/incarceration/recidivism

Henggeler,Pickrel,& Brondino,1999



Alcohol and marijuanausePsychiatric SymptomsArrest/incarceration/recidivism

Henggeler,Clingempeel,Brondino, &Pickrel, 2002

MST vs. standardcommunity-basedservices; 4 yearfollow-up


Alcohol and marijuanauseCriminal BehaviorIllicit Drug UsePsychiatric SymptomsArrest/incarceration/recidivism

Schoenwald,Halliday-Boykins,& Henggeler,2003

Multi-sitecomparison of MST

n = 233 familiesn = 66 therapists(16 teams in 9organizations)

AdherenceCriminal offensesSubstance abuseArrests/recidivismSchool suspensionsCaregiver/therapistethnic matchEconomicdisadvantage

Strengthening Families Program

Kumpfer,Molgaard, andSpoth, 1996

Quasi-Experimentalwith 5 yearfollow-up

n = 421 parents and703 high risk youth(6-13 yrs.)

Family conflict/communicationParenting behaviorChild emotional status

Aktan, Kumpfer,& Turner, 1996

Quasi-Experimentalwith matchedcomparison

n = 88 Inner CityAfrican-American youth(age 6-12) and familieswith substance-usingparentn = 56 comparisongroup

Parenting efficacyParental substanceuseRetention/completionin treatment

Kamoeoka, 1996 Quasi-Experimental n = 136 Asian andPacific-Island youthand families

Substance useRetention in treatmentParenting skillsDepressionChildren behaviors

Spoth, Redmond,& Shin, 1998

“Preparing for thedrug free years”program vs. SFPvs. minimal contactcontrol

n = 523 families ofstudents in 33 ruralMidwestern schools

Parenting methodsRetention in treatmentChild academic status




Spoth, Reyes,& Redmond, 1999

“Preparing for thedrug free years”program vs. SFP vs.control follow-up

n = 329 10th gradeadolescents

Current and past use ofAlcohol/tobacco/marijuanaParenting methodsRetention in treatmentChild academic status

Spoth, Redmond,& Lepper, 1999

Longitudinal,efficacy study

n = 446 adolescentsand families

Alcohol initiationbehaviorsParenting methodsRetention in treatmentChild academic status

Spoth, Redmond,& Shin, 2001;Spoth, Guyll,& Day, 2002

“Preparing for thedrug free years”program vs. SFP vs.control

n = 667 6th gradersand their families in 33public schoolsRandom assignment

Cost of treatmentCurrent and past use ofAlcohol/tobacco/marijuanaParenting methodsRetention in treatmentChild academic status

Kumpfer,Alvarado, & Tait,2002

“I Can ProblemSolve” program vs.“I Can ProblemSolve” programcombined with SFPvs. SFP only

n = 655 1st gradersfrom 12 rural schoolsRandom assignment

Social competencySelf-regulationsFamily relationshipsParentingSchool bondingParenting skills

Spoth, Guyll, &Chao, 2003

Exploratory withwait list control

n = 85 African-American families withyouth 10-14 years ofage from generalpopulationRandom selection

Retention ratesTreatment adherenceChild behaviorsChild participation infamily meetingsChild and family livingskills

Brief Strategic Family Therapy

Szapocznik,Santisteban, Rio,Perez-Vidal, &Kurtines, 1986

BSFT vs. BiculturalEffectivenessTraining

n = 41 CubanAmerican adolescentswith a behaviorproblem and familiesRandom assignment

Adolescent problembehaviorsFamily functioning

Szapocznik,Santisteban, Rio,Perez-Vidal,Kurtines, & Hervis,1986

Family EffectivenessTraining vs.Minimum ContactControl

n = 79 Hispanic 6- to11-year-old childrenwith emotional andbehavior problemsand familiesRandom assignment

Structural familyfunctioningChild behaviorproblemsChild self-concept

Szapocznik, 1986 Conjoint familytherapy with entirefamily versusOne-person familytherapy

n = 35 Hispanic-American familieswith drug-usingadolescents

Individual and familyFunctioningBehavioralacculturation


TABLE 1 (continued)



Szapocznik,Kurtines, Foote,Perez-Vidal, &Hervis, 1983,1986

Conjoint familytherapy with entirefamily vs. One-person familytherapy

n = 72 Hispanic drugabusing 12- to17-year-old adolescentand familiesRandom assignment

Youth drug useBehavior problemsFamily functioning

Sazpocznik et al.,1988

Engagement asUsual vs. StrategicStructural SystemsEngagement

n = 108 CubanHispanic families andadolescents suspectedof/observed usingdrugs by their parentsor school counselorsRandom assignment

Engagement intreatmentRetention to treatmentFamily functioning

Szapocznik, Rio,Murray et al.,1989

BSFT vsPsychodynamicChild Therapy vs.Recreational ControlCondition

n = 69 Hispanic boyswith emotional andbehavioral problems(aged 6 to 12)Random Assignment

Emotional andbehavioral problemsRetention in treatmentChild functioningFamily integrity

Santisteban et al.,1996

BSFT plus StrategicStructural SystemsEngagement vs.BSFT plusEngagement asusual vs. groupcounseling plusEngagement asusual

n = 193 HispanicfamiliesRandom Assignment

Engagement intreatmentRetention to treatmentHispanic cultural/ethnicidentity

Coatsworth,Santisteban, &McBride, 2001

BSFT vs. standardcommunity services

n = 104 AfricanAmerican or Hispanicfamilies andadolescents withbehavioral, emotional,academic andsubstance useproblemsRandom Assignment

Engagement totreatmentRetention to treatmentConduct problemsAnxietyDisruptive behaviors

Santisteban,Coatsworth, &Perez-Vidal, 2003

BSFT vs. Grouptreatment control

n = 126 Hispanicfamilies andadolescents withbehavioral problemsand drug-use Randomassignment

Conduct problemsDelinquencySubstance useFamily functioning

Multi-Dimensional Family Therapy

Liddle et al., 2001 MDFT vs. adoles-cent group therapyand multifamilyeducationalintervention

n = 182 clinicallyreferred marijuana andalcohol-abusing 13-18-yr.-olds and familiesRandom Assignment

Substance useActing outGPAFamily competence

The effects of MST on drug use have been examined in trials using ju-venile offenders as participants (Henggeler et al., 1991; Henggeler, Mel-ton, & Smith, 1992; Borduin, Mann, Cone et al., 1995). In these trials,MST significantly reduced self-reported drug use, criminal activity, vio-lence, incarceration (Henggeler, et al., 1992), incarceration recidivism,aggression with peers, family cohesion (Henggeler, Melton, Smith et al.,1993), and drug-related and other arrests (Borduin et al., 1995).




Liddle, in press MDFT vs. Cognitive-Behavioral Therapy

n = 224 African-American males fromlow-income familiesRandom Assignment

Substance useConduct problemsAnxiety/depressionFamily functioning

Dennis et al.,in press

MDFT vs.MotivationalEnhancementTherapy (MET) vs.CognitiveBehavioral Therapy(CBT) vs. FamilySupport Network(FSN), vs.AdolescentCommunityReinforcementApproach (ACRA)vs. MultidimensionalFamily Therapy(MDFT)

n = 600 adolescentsbetween 12- 18 yearsof age, used marijuanain the past 90 days,and met one or morecriteria of abuse ordependenceRandom assignment

Substance useCost and cost/benefitratioSubstance useConduct problemsAnxiety/depressionFamily functioningAcademic behaviors

Hogue, Liddle,Becker, &Johnson-Leckrone, 2002

MDFT vs. controlcondition

n = 124 inner-cityAfrican-Americanyouths (11-14 yrs.)Random assignment

Drug useSelf-competenceFamily functioningSchool involvementPeer associationsGlobal self-worthFamily cohesion

Integrated Behavioral Family Therapy

Waldron, Slesnick,& Brody, 2001

IBFT vs. individualcognitive behavioraltherapy vs.combination

n = 114substance-abusingadolescentsRandom assignment

Substance use

Latimer, Winters,& D’Zurilla, 2003

IBFT vs. “Drug’sHarm” psycho-educationalcurriculum

n = 43 adolescentsmeeting diagnosticcriteria for substanceuse disorder

Alcohol and marijuanauseRational problemsolvingLearning strategy skillsProblem avoidanceskills

An experimentally designed study compared home-based MST withusual community services for 118 substance using juvenile delinquents.MST showed higher rates of client completion of the full course of thetreatment, which averaged 130 days (Henggeler, Pickrel, Brondino, &Crouch, 1996). The MST group showed significantly decreased self-re-ported alcohol and marijuana use, although urine screen results did notconfirm the youth self-reports and the positive outcomes were not main-tained at 6 months post-treatment (Henggeler, Pickrel, & Brondino,1999). However, the MST group showed increased school attendanceand these treatment gains were maintained at 6-month follow-up(Brown, Henggeler, & Schoenwald, 1999). Additionally, it was foundthat the cost of MST was mitigated by the reduced incarceration costs(Schoenwald, Ward, & Henggeler, 1996).

Based on the negative results related to urine screening for substanceuse, several enhancements were made to the MST treatment protocol tothoroughly address adolescent substance use. These enhancementswere based on the Community Reinforcement Approach (CRA), an ap-proach specifically geared toward substance use (Randall & Cunning-ham, 2003; Randall, Henggeler, & Cunningham, 2001). In a recent fol-low-up study, MST was compared with usual community servicesamong substance abusing juvenile offenders four years following par-ticipation. Significantly less aggressive criminal activity was found.While findings for illicit drug use were mixed, significantly higher ratesof marijuana abstinence was found among MST participants (Heng-geler, Clingempeel, Brondino, & Pickrel, 2002).

In terms of adherence to MST, a recent study of 233 families indi-cated that adherence ratings were lower for youths referred for bothcriminal offenses and substance abuse, but not for either referral indi-vidually. Adherence ratings were negatively associated with pretreat-ment arrests and school suspensions, and positively associated witheducation disadvantage and caregiver-therapist ethnic match. Theywere also marginally associated with economic disadvantage (Schoen-wald, Halliday-Boykins, & Henggeler, 2003).

STRENGTHENING FAMILIES PROGRAM

The Strengthening Families Program (SFP) provides a family-basedintervention for families with substance abusing parents aimed at devel-oping drug resistance skills in their children. Framed within the socialecological model of adolescent substance abuse (Kumpfer & Turner,


1990-1991), the SFP holds that the family climate is responsible forchild substance abuse. Based on this model, the family influencesschool bonding and self-efficacy, which in turn determines the amountof peer influence and later alcohol and drug use (Kumpfer, Molgaard, &Spoth, 1996; Kumpfer & Turner, 1990-1991; Oetting, 1992; Newcomb,1992). The SFP program focuses on strengthening the family in order tomediate peer influence related to drug and alcohol use in adolescents.

The highly structured SFP program consists of a 14-week curriculuminvolving parent training, child skills training, and family skills training(Kumpfer et al., 1996). The approach is highly detailed in terms of man-uals and training (Kumpfer et al., 1989). In fact, versions of SFP havebeen culturally-adapted for African-Americans, Hispanic-Americans,Asian/Pacific Islanders, and American-Indian families. The culturallyadapted versions can increase retention, but may reduce positive out-comes (Kumpfer, Alvarado, & Smith, 2002).

SFP references empirical research that focuses on risk and protectivefactors in order to examine the family’s influence on child’s substanceuse. It is believed that a child’s risk of substance use increases as thenumber of risk factors increases relative to protective factors (Kumpferet al., 1996). This is especially true when the level of risk is elevatedabove one or two risk factors (Bry & Krinsley, 1992; Newcomb &Bentler, 1989).

Research suggests that SFP has been effective with substance-abus-ing parents and parents from racial and ethnic minority groups(Kumpfer et al., 1996; Kumpfer & Alvarado, 1995, Kumpfer, Alver-ado, & Tait, 2002; Aktan, Kumpfer, & Turner, 1996; Kamoeoka, 1996;Kumpfer, Wamberg, & Martinez, 1996). In a recent study, 56 rigorousevaluations of interventions for alcohol misuse were reviewed and sum-marized. It was noted that SFP showed promise as an effective preven-tion intervention (Foxcroft, Ireland, & Lister-Sharp, 2003)

The program’s effectiveness was originally established with school-aged children of drug abusers (Kumpfer et al., 1989). Three groups(parent training program only, parent training with a children’s trainingprogram, and parent and child training with a family skills training andrelationship enhancement program) were compared. The study con-cluded that the combined intervention including all three componentscaused the most improvement on: (1) children’s problem behaviors,emotional status, and prosocial skills, (2) parents’ parenting skills, and(3) family environment and family functioning. Each program compo-nent was effective in reducing risk factors targeted by that component.


Subsequent studies have found consistent support for SFP with par-ent and child behaviors and drug use (Aktan, 1995; Aktan et al., 1996),especially for high-risk families (Kumpfer et al., 1996). SFP has alsobeen found effective with modifications for African-American, Hawai-ian, Hispanic, rural, and multi-ethnic families (Spoth, Guyll, & Chao,2003). For example, a five-year follow-up of high risk, ethnic minorityfamilies demonstrated that family management skills were still in usemany years following participation in SFP (Kumpfer et al., 1996).

Using a substance initiation index, Spoth and colleagues have consis-tently found evidence suggesting the potential of SFP to delay the onsetof substance use and the possibility of avoiding substantial costs to soci-ety with relatively small intervention costs (Spoth, Guyll, & Day, 2002;Spoth, Redmond, & Trudeau, 2002; Spoth, Reyes, & Redmond, 1999;Spoth, Redmond, & Lepper, 1999; Spoth, Redmond, & Shin, 1998;Spoth, Redmond, & Shin, 2001; Spoth, Redmond, & Trudeau, 2002). Aseven-session version of SFP, developed for early adolescence andbased on resilience principles, showed positive results during a 5-yearrandomized clinical trial with rural sixth-grade students (Kumpfer,1998). Spoth (1998) also found positive results in terms of tobacco andalcohol rates with this program.

In a recent study (Kumpfer, Alvarado, & Tait, 2002), 655 first gradersfrom 12 rural schools were randomly assigned to either the “I Can Prob-lem Solve” program alone, in combination with SFP, or parent trainingonly. Results suggested that there were significant improvements onschool bonding, parenting skills, family relationships, social compe-tency, and behavioral self-regulation for the group receiving the com-bined intervention. Adding the parenting skills program only, socialcompetency and self-regulation were more improved, but family rela-tionships were negatively impacted. Alternatively, adding SFP improvedfamily relationships, parenting, and school bonding.

BRIEF STRATEGIC FAMILY THERAPY

Brief Strategic Family Therapy (BSFT) was developed through theintegration of theory, research, and practice of structural and strategicmethods (Szapocznik & Williams, 2000). BSFT is especially appropri-ate for treatment of substance use that co-occurs with other behaviorproblems, including conduct disorders, oppositional behavior, delin-quency, associating with antisocial peers, aggressive and violent behav-ior, and risky sexual behavior (Szapocznik, Rio, & Murray, 1989; San-


tisteban, Szapocznik, Perez-Vidal et al., 2000; Newcomb and Bentler,1989; Perrino, Gonzalez-Soldevilla, Pantin & Szapocznik, 2000).BSFT is a family-based intervention specifically created to address con-duct problems and drug abuse among Hispanic (Szapocznik & Wil-liams, 2000; Robbins, Szapocznik, & Santisteban, 2003; Robbins,Mitrani, & Zarate, 2002) and African American youths (Szapocznik &Williams, 2000), and has been proposed for use with other populationsas well, such as Chinese Americans (Soo-Hoo, 1999).

Three basic principles typify BSFT: The family as a system, struc-ture/patterns of interactions, and strategy (Szapocznik & Kurtines,1989). The concept of family systems reflects the understanding thatfamily members are interdependent and that individual behaviors affectothers in the family. The structure/patterns of interactions indicate thatthe behaviors of family members are habitual and repeat over time. Thisstructure contributes to behavior problems, such as substance abuse andBSFT targets these interactions. The third principle relates to the notionthat intervention must be practical and deliberate, and linked directly toproblem behaviors (Szapocznik & Williams, 2000).

BSFT is built into the youth’s daily family life and can be implementedin eight to twenty-four sessions. The therapy is manualized (Szapocznik,Hervis, & Schwartz, 2001), with training programs available. BSFT is aflexible approach that appeals to cultures that emphasize family and inter-personal relationships. BSFT has been well established in the treatmentof adolescents with problems ranging from substance use to conductproblems, associations with antisocial peers, and impaired family func-tioning (Szapocznik, Perez-Vidal, Hervis et al., 1989).

Engagement and retention issues have also been examined, with en-couraging results. Structural Strategic Systems Engagement was devel-oped specifically in relation to family therapy, with the belief thatresistance to treatment can be understood in terms of family interactions(Szapocznik & Kurtines, 1989; Szapocznik et al. 1989). Studies haveshown positive results in engaging and retaining clients in BSFT(Coatsworth, Santisteban, & McBride, 2001), and in Structural Strate-gic Systems Engagement specifically (Santisteban, Szapocznik, Perez-Vidal et al., 1996; Szapocznik, Perez-Vidal, Brickman et al., 1988).

In clinical trials, BSFT has been compared with other therapies. Indi-vidual psychodynamic child therapy and a recreational control condi-tion were compared with BSFT in a randomized study with sixty-nineHispanic boys with emotional and behavioral problems, aged six toeleven. Findings indicated that the control condition was significantlyless effective in retaining cases, the two treatment conditions were equally


effective in reducing emotional and behavior problems, and the BSFTgroup alone reported continued significant improvement of family func-tioning at the one-year follow-up (Szapocznik, Rio, & Murray, 1989; Szap-ocznik, Santisteban, Rio et al., 1986).

Other studies have compared BSFT in conjunction with other methods.For example, BSFT was compared to a Bicultural Effectiveness Training;however, no significant differences were found (Szapocznik et al., 1986).Following these results, the researchers compared a combination of BSFTand Bicultural Effectiveness Training (Family Effectiveness Training) andgroup controls. The Family Effectiveness Training condition showed sig-nificantly greater improvement than control families on structural familyfunctioning, child behavior problems, and child self-concept (Szapocznik,Santisteban, Rio et al., 1986).

Two types of BSFT have also been compared: conjoint family therapy(including the entire family) with one-person family therapy. In a studywith 35 Hispanic-American families (Szapocznik, Kurtines, Foote, Perez-Vidal, & Hervis, 1983), it was found that one-person family therapy was aseffective as conjoint family therapy in reducing youth drug use and behav-ior problems, as well as improving individual and family functioning. Ad-ditionally, one-person family therapy was more effective in sustainingimproved family functioning at follow-up (Szapocznik, Kurtines, Foote,Perez-Vidal, & Hervis, 1986).

BSFT has been shown to be effective with adolescent behavior prob-lems. One study (Santisteban et al., 2000) reviewed the ability of BSFT toreduce behavior problems in twelve to eighteen year old Hispanic adoles-cents and their families. In this study, BSFT was compared to a group con-trol condition. Adolescents in the BSFT condition showed significantlydecreased levels of conduct disorder and socialized aggression from pre- topost-treatment, while the control condition showed no change. Another re-cent study compared BSFT to a group treatment control (Santisteban,Coatsworth, & Perez-Vidal, 2003). One hundred twenty-six Hispanic fam-ilies were randomly assigned to one of the two conditions. BSFT familiesshowed significant improvement in conduct problems and delinquency, aswell as marijuana use and family functioning.

MULTIDIMENSIONAL FAMILY THERAPY (MDFT)

Multidimensional Family Therapy (MDFT) focuses on changingsystemic influences that establish and maintain problem behaviors inadolescents. MDFT was first introduced as a weekly, clinic-based inter-


vention (Liddle & Hogue, 2000). A newer version provides a home-based, intensive intervention that incorporates alterations for severelyimpaired co-morbid substance abusing youth. MDFT is based on the in-tegration of existing therapeutic work in areas such as case manage-ment, school interventions, drug counseling methods, use of multi-media, and HIV/AIDS prevention (Rowe, Liddle, & McClintic, 2002).

MDFT is manualized and treatment duration and intensity has beentested for 16 sessions over five months, as well as a variable number ofsessions over six months. Generally, an average of 2-3 sessions withvarious combinations of family members is held weekly, averaging 1-2hours each. Phone contacts should be frequent and provide opportuni-ties for “mini-sessions.” MDFT assesses and intervenes in five do-mains: Interventions with the adolescent, parent, parent-adolescentrelationship, other family members, and systems external to the family(Liddle & Dakof, 1995). MDFT encompasses a collaborative, individu-alized approach that requires a high degree of engagement by families.Strategies for engagement is employed to capture the interest of thefamily and assess risk and protective factors within the specific ecologi-cal context of the family in order to create a working agenda for preven-tive intervention (Becker, Hogue, & Liddle, 2002).

MDFT has been empirically supported as a therapy for substanceabusing teens. Its efficacy has been supported by studies comparingMDFT with alternate therapies in four controlled trials (Dennis, Titus,Diaond et al., in press; Hogue, Liddle, Becker, & Johnson-Leckrone,2002; Liddle et al., 2001). Specifically, three randomized clinical trialshave explored the use of MDFT with adolescent substance use cessa-tion. The first study split 182 substance-using adolescents of varyingethnicities into three groups: MDFT, Adolescent Group Therapy, andMultifamily Education Intervention (Liddle et al., 2001). The resultsshowed overall improvement for all three groups, but the greatest im-provement for the MDFT group. Only the MDFT group reported signif-icant improvement in family competence and academic grades. TheMDFT group also maintained the improvement at 3-month and 12-month follow-ups.

The second study compared MDFT to Cognitive-Behavioral Ther-apy (Liddle, Dakof, Turner, & Tejeda, in press). The clients were pri-marily African-American males from low-income families. It wasfound that both treatments were somewhat efficacious from intake totermination. However, clients who participated in MDFT maintainedgains after termination. The third study focused on issues of cost andsuggested that MDFT compared favorably in terms of cost (less than the


median). MDFT was also found to have an impact that was maintainedat three-month follow-up (Dennis et al., in press).

A prevention study with Multidimensional Family Prevention (MDFP)(Hogue & Liddle, 1999; Liddle & Hogue, 2000) showed greater gainswhen compared to controls on mediators of substance use. Domainsstudied included self-competence, family functioning, school involve-ment, and peer associations. Preliminary evidence of short-term efficacyindicated strengthened family cohesion, school bonding, and reduced peerdelinquency compared to controls (Hogue et al., 2002).

INTEGRATED BEHAVIORAL FAMILY THERAPY

There is some evidence for the effectiveness of IBFT, especially interms of long-term maintenance of results. The therapy combines twocommon and well-established family treatment approaches for adoles-cent substance abuse: family systems therapy and individual cogni-tive-behavioral therapy. IFBT has been manualized and typicallyincludes weekly or bi-weekly meetings with the adolescent and the par-ents. The duration of the intervention usually ranges from a few monthsto a year, depending on the need for the intensity of the treatment.Booster sessions have been used following termination of treatment,and are recommended beginning at three months after treatment termi-nation, as this is a typical time for recurrences in substance abuse(Whisman, 1990). The use of IFBT with minority clients has also beenexplored (Moncher, Holden, & Schinke, 1990).

IBFT (also known as Targeted Family Intervention) involves assess-ment and intervention based on assessment. During the assessmentphase, the therapist elicits statements regarding desired outcomes, as-sesses past attempts to address the problem, collects information aboutcurrent reinforcement of the problem, and elicits maladaptive explana-tory statements from the family. The intervention goal is to help fami-lies establish environments that will promote desired behaviors. This isaccomplished by taking one complaint at a time, modeling and coachingnon-aversive communication behaviors, modeling and guiding membersthrough sequential verbal problem-solving, focusing on consistent con-sequences for undesired behavior, and suggesting evidence for moreadaptive explanatory statements about undesired outcomes (Bry &Krinsley, 1992).

In a randomized trial comparing IBFT, individual cognitive-behav-ioral therapy, and IBFT combined with individual cognitive-behavioral


therapy, each intervention demonstrated a level of efficacy (Waldron,Slesnick, & Brody, 2001). However, the IBFT alone and in combinationwith individual therapy showed a significant decrease in days of sub-stance use. In order to explore ways to lengthen the effects of IBFT andother family therapies, the long-term effects of IBFT on substanceabuse have been examined. In a small group of subjects receiving IBFT(n = 1 control, 3 experimental), maintenance of decreased substance usewas seen after six months in youth that received booster sessions (Bry &Krinsley, 1992).

In another recent study (Latimer, Winters, & D’Zurilla, 2003), IBFTwas compared with a psychoeducational curriculum. Forty-three sub-stance abusing youth participated in the study. During the 6-monthpost-treatment period, the IBFT group showed significantly lower ratesof alcohol and marijuana use, and problem avoidance; significantlyhigher levels of rational problem-solving and learning strategy skillswas also found.

OTHER FAMILY THERAPIES

Other family therapies have been developed and are currently beingexamined; however, limited empirical support exists. Some of the lead-ing therapies in this category will be discussed briefly and include:Purdue Brief Family Therapy, Project STAR, the Seattle Social Devel-opment Project, and the Community Reinforcement Approach andFamily Training.

Purdue Brief Family Therapy (PBFT) integrates structural, strategic,functional, and behavioral family therapies. Goals include reduction of re-sistance to change, restraint of immediate change, reestablishment of pa-rental control, assessment, and interruption of dysfunctional patterns,provision of adolescent assertion skills training and positive therapeuticchanges (Trepper, Piercy, & Lewis, 1993). In a study of 84 adolescents andtheir families (Lewis, Piercy, & Sprenkle, 1990), the Purdue Brief FamilyTherapy model was compared to a parenting skills program. Both pro-grams were found to significantly reduce drug use, but a greater percentageof the PBFT group showed decreased drug use.

Project STAR has gained recognition focusing on prevention with pre-school children. The program includes a classroom-based curriculum andalso parent training and home visits. In a longitudinal study (Kaminski,Stormshak, Good, & Goodman, 2002), Head Start classrooms were ran-domly assigned to experimental and control groups. An increase in posi-


tive parenting and parent-school involvement over the first year of inter-vention and positive parenting and social competence through kindergar-ten suggests the possible usefulness of this program in preventing sub-stance abuse.

The Seattle Social Development Project (SSDP) is based on the socialdevelopment model, which incorporates empirical predictive and protec-tive factors related to antisocial behavior in adolescents. The social devel-opment model is based on control theory, social learning theory, anddifferential association theory (Catalano & Hawkins, 1996). One study(Lonczak, 2000) found encouraging results for risky sexual abuse in ado-lescents. Additionally, it has been tested for use with adolescent substanceuse and findings indicate that the model’s factors are potential targets forthe prevention or reduction of adolescent alcohol use (Lonczak, Huang, &Catalano, 2001; Catalano, Kosterman, & Hawkins, 1996). Positive effectsof the program have been found for students’ attitudes, achievement, andbehavior (Hawkins, Catalano, & Morrison, 1992).

CONCLUSIONS

From this review of the literature it is evident that most studies indi-cated the effectiveness of family-based interventions in reducingyouth substance use behaviors. Although the findings are somewhatinconclusive concerning the lasting effects, the evidence clearly indi-cates that these interventions are helpful in reducing youth substanceuse and other high-risk behaviors. Various studies demonstrated thatthe short-term effectiveness of these interventions appear comparableto the effectiveness of individually based interventions; however,long-term effects of family-based interventions appear more promis-ing than adolescent therapy alone. Also encouraging is the fact thatthese treatments are manualized, making future replication possible.

However, many of the studies reviewed used quasi-experimental orexploratory methods with a small sample sizes. Very few studies meet thecriteria for strong validity in experimental design and sensitivity (Spoth,1998). Additionally, the validity of some studies is questionable, asself-report measures of substance use and other highly sensitive issueswere employed. Some studies measured potential substance use based onindirect measures, such as drug-related arrests or family functioning mea-sures. Clearly, the issue of social desirability in self-report findings mayaffect the validity of the results; thus, future studies on family-based inter-


ventions must utilize multi-method, multi-informant measurement proce-dures.

Although adaptation of existing successful family-based models to ad-dress substance use among youth is needed, few studies of family-based in-terventions addressed the serious problem of engagement and retention inthe treatment process. Research has shown that time in treatment (reten-tion) is the single best predictor of positive outcomes (Simpson, 2001) andhigher levels of engagement early in treatment lead to extended retentionrates (Joe, Simpson, & Broome, 1998; Simpson, Joe, Rowan-Szal, &Greener, 1995). Engagement is typically defined across general dimen-sions of therapeutic involvement and session participation (Joe et al., 1998)and involves rapport, treatment confidence, and commitment (De Leon,1996; Simpson, Joe, & Brown, 1997). Thus, a client who is ‘engaged’ ismore likely to bond with counselors, endorse treatment goals, and partici-pate to a greater degree (Broome, Joe, & Simpson, 2001). In addition, ahigh degree of treatment readiness is considered an important predictor ofclient participation and positive outcomes (Broome, Knight, Hiller, &Simpson, 1997; Gainey, Wells, Hawkins, & Catalano, 1993). Treatmentretention is highly associated with engagement and, like engagement, isconsidered an important criterion for judging the effectiveness of an in-tervention (Szapocznik & Kurtines, 1990). These studies point to theneed for further development and research of strategies to improve en-gagement and retention, especially for difficult to recruit and retain popula-tions.

In light of these findings, more studies are needed to explore the use offamily-based interventions for this population. These findings should bereplicated in experimental studies with larger sample sizes and more rigor-ous methodologies. Additionally, the treatments should be studied acrossdiverse ethnic groups, and developed with cultural sensitivity. Given theencouraging results related to the long-term effects of family-based inter-ventions on adolescent substance use, factors related to these positive find-ings should be explored in more depth.

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